Stingray Envenomation: A Retrospective Review of Clinical Presentation and Treatment in 119 Cases

Richard F. Clark MD^{, †,} , Robyn Heister Girard MD^†, Daniel Rao MD^{, †}, Binh T. Ly MD^{, †} and Daniel P. Davis MD^†
†Department of Emergency Medicine, University of California, San Diego Medical Center, San Diego, California
Division of Medical Toxicology, University of California, San Diego Medical Center, San Diego, California
Received 17 January 2006;  revised 12 November 2006;  accepted 3 February 2007.  Available online 30 May 2007.

Reprint Address: Richard F. Clark, md, 200 W. Arbor Dr., San Diego, CA 92103-8676

Journal of Emergency Medicine
Volume 33, Issue 1, July 2007, Pages 33-37

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July 07, 2007 — PSDiver Monthly Issue 40

Issue 40 of PSDiver Monthly is now available for download
Click to launch to www.PSDiverMonthly.com.

  IN THIS ISSUE of PSDiver Monthly

** A young boy and his father are enjoying a sailboat ride on the lake when a sudden storm flips the boat. The 6 year old and his father are thrown into the water and are kept afloat by their lifejackets. As the sailboat sinks in over 100′ of water, the boy becomes entangled in the rigging is is pulled from his fathers grip. The ensuing search and recovery effort is intense.

**A study on heavy metal contaminates in LA Harbor.

**Flooding in various parts of the world is creatnig a variety of problems for flood and swift water rescue teams. Read about some of the events that have occured as a result of the flooding.

**News of Interest for Public Safety Dive Teams and Water Rescue and Recovery Teams

**PSDM Issue 40 Continuing Education

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About PSDiver Monthly

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PSDiver Monthly is an Internet E-zine specifically designed for Public Safety Divers and Water Rescue Technicians. News articles and information from around the world as well as independent articles, special features, safety notices and continuing education will be shared in each issue.

Corporations who believe in the work that Public Safety Divers and Water Rescue and Recover Teams perform and who wish to show their support sponsor this e-zine. This is and will be the place to get the most current news affecting the Public Safety Diving and Water Rescue community as well as the most current equipment and ocassionally, special pricing from our sponsors.

Fire Department Dive Teams, EMS Dive Teams, Police Divers, SAR divers and Flood and Swift Water rescue teams should all benefit from this publication.

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WEST PALM BEACH, Fla. — State officials have been asked to investigate the closure of an emergency hyperbaric chamber by a West Palm Beach hospital.Divers have protested the move by St. Mary’s Medical Center to discontinue its emergency hyperbaric oxygen services — which are used to treat “the bends.”The bends, or decompression sickness, is caused by nitrogen gas bubbles that can form in a diver’s lungs and bloodstream as he moves from deeper water toward the surface.

The results can include restricted blood flow and damaged blood vessels.The services are not available anywhere in the county, and the nearest chamber is in Miami.A spokeswoman said Florida Attorney General Bill McCollum is investigating whether St. Mary’s decision violated its purchase agreement, days after Palm Beach County Health Director Jean Malecki asked McCollum’s office to intervene.Doctors said transporting divers with the bends long distances puts patients at a greater risk because more time elapses before treatment.

Winthrop celebrates the dedication of its new Hyperbaric Medicine Center. Cutting the ribbon are (l.-r.) John DaVanzo, Trustee, Village of Mineola; Scott Gorenstein, MD, Clinical Director of the Hyperbaric Medicine Program; Daniel P. Walsh, President and CEO of Winthrop; Rochelle Battino, Administrative Director of the Wound Healing Center and Hyperbaric Medicine Program; John Collins, Winthrop’s Chief Financial Officer and Chief Operating Officer; Lewis E. Williams, MD, Medical Director of the Wound Healing Center; and Daniel Abbruzzese, Vice President for Facilities Management at Winthrop.

In response to the growing need for specialized medical care for non-healing wounds, Winthrop-University Hospital recently opened a comprehensive Wound Healing Center and Hyperbaric Medicine Program.

Non-healing wounds can occur for many reasons, from poor circulation and diabetic neuropathy to complications following surgery and even ill-fitting footwear. The need for expert wound care has increased in recent years for several reasons, including the notable rise in type 2 diabetes, which often leads to non-healing wounds in the feet and legs. Also, with people living longer, there are more senior citizens, who often require assistance with non-healing wounds.

Winthrop-University Hospital’s new comprehensive Wound Healing Center and Hyperbaric Medicine Program provides patients with expert and specialized treatment of persistent wounds. The Wound Healing Center at Winthrop employs a team approach, drawing upon the expertise of vascular surgeons, orthopaedic surgeons, plastic surgeons, podiatrists, infectious disease specialists and internists, as well as nurses, medical assistants, diabetologists and orthotists.

“Our mission is the healing of all wounds referred to us,” said Lewis E. Williams, MD, Medical Director of the Wound Healing Center. “In our evaluation and management of the patient, we take into account any adverse aspect that could interfere with the wound healing process. By utilizing the extensive resources of our Wound Healing Center and Hyperbaric Medicine Program, we can offer tremendous healing potential for our patients.”

The Center utilizes a great array of treatment options that have been made possible by recent scientific advances in wound healing. Among those options is the new Hyperbaric Medicine Program, which employs pure oxygen and atmospheric compression to promote the healing of wounds that were unresponsive to other treatments.

Hyperbaric therapy has proven to be an extremely useful tool in the treatment of non-healing wounds, and has helped many patients to avoid amputations that at one time would have been considered inevitable.

“Hyperbaric oxygen therapy has been used to treat a variety of medical conditions,” said Scott Gorenstein, MD, Clinical Director of Winthrop’s Hyperbaric Medicine Program. “Most commonly hyperbaric oxygen is used to promote healing in patients with diabetic wounds, however here at Winthrop we also look forward to treating patients with a variety of other conditions, such as the side affects from radiation therapy.”

The hyperbaric units at Winthrop are constructed of clear materials, which reduce discomfort in patients who experience confinement anxiety. They are large enough for a patient to comfortably read a book, and are equipped with individual flat-screen televisions and access to an extensive library of movies.

In addition, each hyperbaric unit at Winthrop is outfitted with a profile screen identical to the one monitored by the technician, which allows the patient to watch his or her progress throughout the treatment. The hyperbaric chambers are climate controlled for patient comfort, with two-way communication with the technician or doctor. The chambers at Winthrop are the largest individual-size units available today, able to accommodate individuals weighing up to 700 pounds.

During hyperbaric oxygen therapy treatment, the patient breathes 100 percent oxygen while enclosed in a pressurized chamber. Inhaling the pure oxygen allows greater amounts of oxygen (up to five times more than normally) to be absorbed into the bloodstream and then carried to the tissue that needs improved healing. The consistent delivery of pure oxygen to the affected site(s) encourages the growth of new blood vessels within the wound and eliminates certain poisons that may have hampered previous treatments, while improving the body’s response to infection.

Winthrop currently has three hyperbaric chambers installed, with a fourth to follow to allow for flexible and accommodating scheduling.

As a major regional healthcare provider, Winthrop provides comprehensive care to its patients. The creation of a multidisciplinary Wound Healing Center and Hyperbaric Medicine Program at Winthrop is a welcome extension of the Hospital’s commitment to providing a complete complement of care to the community.

For additional information about the Wound Healing Center and Hyperbaric Medicine Program at Winthrop, please call (516) 663-8498.

BMJ 1997;314:689 (8 March)

Editorials

Brain damage in divers

Diving itself may cause brain damage–but we need more evidence

Introduction

Diving involves risk of neurological injuries. These may arise from decompression illness (a label which recognises the difficulty in distinguishing clinically decompression sickness due to gas nucleation from gas invasion caused by pulmonary barotrauma), anoxia (caused by near drowning), and the toxic effects of high partial pressures of breathing gases. The possibility that divers and others working in hyperbaric conditions may acquire neuropsychological damage without a clear history of a precipitating event is worrying. Since 1978 five international meetings have discussed this possibility, but no consensus exists whether diving per se causes brain damage.

Much of the evidence of functional abnormalities in divers with no history of decompression illness is anecdotal. Many reports describe findings in mixed groups of divers, some with and some without prior decompression illness.1 2 The most quoted study involved a snapshot assessment of intellectual function in Australian abalone divers,3 with no assessment of change over time and no controls. The psychological assessment probably failed to reflect the characteristics of these particular individuals, and their dive practices.

Nevertheless, degeneration and vasculopathy are seen after death in the brains and spinal cords of unaffected divers which resemble the abnormalities found after decompression illness.4 5 Retinal fluorescein angiography in divers with no history of decompression illness has demonstrated vasculopathy, which may be a marker for neurovascular injury.6 Concern is heightened by evidence of long term injuries to other organs, such as crippling dysbaric osteonecrosis in divers and caisson workers years after hyperbaric exposure.

When neurological damage occurs in divers the prime suspects are gas bubbles. Gas nucleation is generally accepted to be the initiating event in most of the syndromes collectively known as decompression sickness. However, free gas does not invariably lead to decompression sickness. Doppler ultrasound can detect “silent” bubbles in the venous blood of many asymptomatic divers. Most bubbles are filtered out by the pulmonary capillaries. It was once believed that a critical amount of gas nucleation was required before decompression sickness occurred. We now know that this may be true for extreme decompressions in individuals without intracardiac or pulmonary right to left shunts, but in those with a shunt a relatively small bubble load can result in paradoxical gas embolism.7 8

Decompression sickness can affect many systems, but the serious effects are neurological. There is usually abrupt or rapid evolution of a focal central neurological deficit (or deficits). The injury may be mild or severely disabling; it may be permanent or resolve spontaneously or with treatment with oxygen and recompression; episodes may recur. Clinically the spectrum of neurological decompression sickness resembles that of thromboembolic cerebrovascular disease, with one exception: decompression sickness commonly affects the spinal cord. This difference may be explained by the considerable gas load in the cord at the end of many dives compared with the gas content of an equivalent weight of brain tissue. The greater blood flow to the brain means that more gas bubbles embolise the brain, but more dissolved gas is available to amplify embolic bubbles in the cord. Conceivably recurrent subclinical decompression sickness may result in a condition analogous to multi-infarct dementia with gas embolism rather than thromboembolism as the initiator.

There are other neurological insults. During many normal dives neurological effects occur from variations in gas partial pressures. Every depth change of 7 m produces change in ambient pressure equivalent to a trip between sea level and the top of Mount Everest. The narcotic effects of nitrogen at depths of 30 m or less are well described. Narcosis is reversed by ascent but can repeated exposure cause target organ damage like repeated alcohol intoxication? Other breathing gases are also not inert at high partial pressures. Oxygen is neurotoxic. Very deep dives, during which mixtures containing helium are breathed, can result in the high pressure neurological syndrome, which causes excitatory effects including tremor, myoclonus, and convulsions. Repeated insults might produce permanent harm.

Until recently investigational techniques were too insensitive to detect neurological abnormalities in “normal” divers or even in those with clinical effects from decompression illness9. Magnetic resonance imaging seems to offer greatest promise. Reul and colleagues found more hyperintense subcortical white matter lesions in the brains of sport divers than in non-diving controls.10 The difference was due to a subgroup of divers who had multiple brain lesions. In this issue Knauth and colleagues report that multiple brain lesions on magnetic resonance scans in sport divers occur exclusively in those with large right to left shunts (presumed to be patent foramen ovale, though some may be small atrial septal defects or pulmonary arteriovenous shunts) (p 701).11

These observations are consistent with the well documented role of shunts in the pathogenesis of overt decompression illness by means of paradoxical gas embolism but extend this role to subclinical injury. This is plausible. Decompression illness is a spectrum. It may be so mild that divers do not seek treatment.8 Divers who have had decompression illness and in whom we find a large shunt often recollect mild neurological symptoms after earlier dives which they did not consider important at the time. The fact that the illness can be mild adds plausibility to studies showing an increased prevalence of subclinical lesions in divers with a large shunt but also cautions against accepting data uncritically from studies in which subjects were self selected.10 11

The results of magnetic resonance scans in others exposed to hyperbaric conditions have not been entirely consistent. Caisson workers also have an increased prevalence of brain lesions.12 Professional divers do not,13 even though necropsy evidence of pathological injury is commoner than in sport divers.5 Magnetic resonance imaging does not always reveal abnormalities in cases of clear neurological decompression illness.14 These apparent contradictions may be due to differences in imaging techniques, methods of subject recruitment, and confounding variables. Interestingly, magnetic resonance findings do not correlate with the results of psychometric tests or electroencephalograms.12 13 Further investigation into the possibility that diving per se causes brain damage is required, but we must not forget that evidence of pathological change is not proof of functional deficit.

Peter Wilmshurst, Consultant cardiologist a

a Royal Shrewsbury Hospital, Shrewsbury SY3 8XQ

Vaernes RJ, Eidsvik S. Central nervous dysfunctions after near miss accidents in diving. Aviat Space Environ Med 1982;53:803-7.

Todnem K, Nyland H, Skiedsvoll H, Svihus R, Rinck P, Kambestad BK, et al. Neurological long term consequences of deep diving. Br J Indust Med 1991;48:258-66.

Edmonds C, Boughton J. Intellectual deterioration with excessive diving (punch drunk divers). Undersea Biomed Res 1985;12:321-6.

Palmer AC, Calder IM, Hughes JT. Spinal cord degeneration in divers. Lancet 1987;ii:1365-6.

Palmer AC, Calder IM, Yates PO. Cerebral vasculopathy in divers. Neuropathol Appl Neurobiol 1992;18:113-24.

Polkinghorne PJ, Sehmi K, Cross MR, Minassian D, Bird AC. Ocular fundus lesions in divers. Lancet 1988;ii:1381-3.

Moon RE, Camporesi EM, Kisslo JA. Patent foramen ovale and decompression sickness in divers. Lancet 1989;i:513-4.

Wilmshurst PT, Byrne JC, Webb-Peploe MM. Relation between interatrial shunts and decompression sickness in divers. Lancet 1989;ii:1302-6.

Halsey MJ, Elliott DH, eds. Diagnostic techniques in diving neurology. London: Medical Research Council Decompression Sickness Panel, 1987.

Reul J, Weis J, Jung A, Willmes K, Thron A. Central nervous system lesions and cervical disc herniations in amateur divers. Lancet 1995;345:1403-5. [Medline]

Knauth M, Ries S, Pohlmann S, Kerby T, Forsting M, Daffertshofer M, et al. Multiple brain lesions in sport divers: the role of a patent foramen ovale. BMJ 1997;314:701-5.

Fueredi GA, Czarnecky DJ, Kindwall EP. MR findings in the brains of compressed-air tunnel workers: relationship to psychometric results. AJNR 1991;12:67-70

Todem K, Skeidsvoll H, Svihus R, Rinck P, Riise T, Kambestad BK, et al. Electroenceph Clin Neurophysiol 1991;79:322-9.

Warren LP, Djang WT, Moon RE, Camporesi EM, Sallee DS, Anthony DC, et al. Neuroimaging of scuba diving injuries to the CNS. AJR 1988;151:1003-8.

SOUTHAMPTON, Pa., July 5 /PRNewswire-FirstCall/ — Environmental Tectonics Corporation (”ETC” or the “Company”) announced today that it had signed a contract for 24 BARA-MED(R) monoplace chambers, valued at over two million U.S. dollars, with Koike Medical Co., Ltd., ETC’s hyperbaric distributor in Japan.

All chambers will be computer-controlled and will include ETC’s patient- friendly Smooth-Ride(TM) compression protocol. The chambers will also be outfitted with standard connectors to ensure compatibility with Radiometer and Perimed transcutaneous oxygen monitors, and with Koike Medical’s BARAMO, a hyperbaric-compatible critical care monitor that includes ECG, temperature, respiration, pulse / heart rate, and non-invasive blood pressure.

Russell E. Peterson, Ph.D., Director of the BioMedical Systems Group, stated, “The Japanese hyperbaric chamber market is one of the largest in the world and is very important to us. We are pleased that Koike Medical is continuing to expand their presence in this competitive market and are projecting significantly more sales of the BARA-MED(R) monoplace in the coming year.”

Currently, both in the United States and overseas, only a small percentage of hospitals offer hyperbaric oxygen therapy (HBO). The number of chambers is increasing, however, as the benefits of hyperbaric medicine become more widely recognized by mainstream medicine. ETC’s BioMedical Systems Group and our customers remain at the forefront of hyperbaric medicine, in equipment, research, and application. In addition to their regular use in clinical treatments at some of the best medical facilities around the world, ETC hyperbaric chambers are routinely involved in research on new indications for which HBO holds promise, and on the refinement of treatment protocols for established indications.

ETC designs, develops, installs and maintains aircrew training systems, public entertainment systems, process simulation systems (sterilization and environmental), clinical hyperbaric systems, environmental testing and simulation systems, and related products for domestic and international customers.

Contact: Duane D. Deaner, CFO
Tel: 215-355-9100 (ext. 1203)
Fax: 215-357-4000
ETC - Internet Home Page: http://www.etcusa.com

UHMS Gulf Coast Chapter Annual Scientific Meeting
Loews Vanderbilt Hotel
Nashville, Tennessee
August 30 - September 1, 2007 (Labor Day Weekend)

For Registration Information CLICK HERE or go to http://www.uhms.org/Chapters/GCC/GCC%202007/GCC_ASM_2007.htm

For More Information Contact Suzanne Pack (UHMS GCC Secretary) at 210-614-3688 or email at gcc@uhms.org.